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Full text of "United States Navy Medical News Letter Vol. 34 No. 8, 23 October 1959"

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Rear Admiral Bartholomew W. Hogan MC USN - Surgeon General 
Captain Donald R. Childs MC USN - Editor 



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Vol. 34 



Friday, 23 October 1959 



No. 8 



TABLE OF CONTENTS 



ABSTRACTS 



DENTAL SECTION 



Thromboembolism 2 

Eosinophilic Peritonitis 4 

Procaine in Intestinal Obstruction 5 

Abdominal Aortic Homograft. ... 6 

X-Ray Changes in S. C. Anemia . 8 

Histoplasmosis 9 

Kidney in Heart Failure . 12 

Test for Hyperthyroidism 14 

Physician's Role in Alcoholism . 15 

MISC ELLANEO US 

In Memoriam 17 

Professional Meetings 17 

Operation "Deep Freeze — 61". . . 19 

Aspects of Missile Operation ... 20 
Medical and Dental Equipment 

(BuMed Inst. 6700. IB) 20 

Name-Plate (BuMed Inst. 5512. 2) 20 

Recent Research Reports 21 

From the Note Book 22 



Pulp Capping 24 

Submarine Dental Standards .... 25 

NDS Training Program 25 

"Navy Dental Corps"- New Film . 26 

Personnel News 26 

RESERVE SECTION 

Tables of Organization 27 

American Board Certifications. , 30 
Association of Military Surgeons 31 

AVIATION MEDICINE SECTION 

Cardiac Stress Two-Step Test . . 32 

Middle Ear Pressure Changes . . 34 

Parachute Descent and Landing . 36 

Physical Disqualification 38 

Qualifications for NATTU 38 

Standard Form 88 39 

Accident Reports 39 



Message from the Surgeon General 40 



Medical News Letter, Vol. 34, No. 8 



Thromboembolism 



Little has been added to the century-old concept, as proposed by Virchow, 
of the fundamental thrombotic changes which may lead to pulmonary embolism. 
Resting on the postulates which he proposed, the factors involved are: (1) 
trauma to the vein wall, (2) venous stasis, and (3) changes in the coagulability 
of the blood. 

Over the course of years, the authors have become impressed with the 
vagaries in signs and symptoms of both venous thrombosis and pulmonary em- 
bolism and with the frequent inability to make a definitive clinical diagnosis of 
these entities. Although results with anticoagulant therapy of thromboembolic 
disease seem to have been responsible for salvage of patients who might other- 
wise have died from fatal pulmonary embolism, the total number of deaths 
from pulmonary emboli has shown little alteration, largely because of failure 
to diagnose the majority of thromboembolic phenomena prior to the patient's 
death from embolism. In addition, the clinical impression of the authors is 
that the nonspecific measures (oxygen and papaverine) presently available for 
treatment of the acute phase of pulmonary embolism have not altered the 
immediate mortality; anticoagulant therapy following pulmonary embolism is 
of value only in prevention of subsequent emboli in a patient who has not suc- 
cumbed to the first embolus. 

Impressed by the fact that the true frequency of pulmonary embolism 
(and, therefore, venous thrombosis as well) is much higher than most clin- 
icians realize, the authors conducted a survey of cases of pulmonary embol- 
ism diagnosed at autopsy. The objectives were: (I) to attempt improvement 
of clinical diagnostic accuracy; (2) to clarify treatment philosophy; and (3) to 
accumulate more information concerning epidemiologic factors. 

During the 10-year period, 1945 - 1954, there were 4,391 complete 
autopsies, excluding stillbirths. Of this group, 606 (13.8%) had pulmonary 
arterial emboli. The embolus was thought to be the sole immediate cause of 
death in 198 patients, a contributory factor in 190, and of minor significance 
in 2 18 patients. 

Since 80% of patients with "minor" pulmonary emboli had no clinical 
sig;ns, the information on clinical manifestations of pulmonary embolism was 
restricted to those patients with significant emboli. The occurrence is: 

Signs and Symptoms 

No definitive sign or symptom 

Dyspnea 

Shock 

Chest pain 

Chest pain, dyspnea 

Chest pain, hemoptysis 

Chest pain, dyspnea, hemoptysis 



Episodes 
137 


P 


ercentage 
27 


291 
138 




58 
28 


110 




22 


75 




15 


29 

14 




6 
3 



Medical News Letter, Vol. 34, No. 8 



(continued) 

Signs and Symptoms Episodes Percentage 
Physical signs 29 6 

Friction rub 16 3 

Hemoptysis 54 11 

Cough and fever were infrequent, and tachycardia and leucocytosis 
presented so much difficulty in interpretation that these features were con- 
sidered of little diagnostic value in the usual patient. 

Because so few of these episodes of pulmonary embolism were diag- 
nosed or even suspected, roentgenograms taken in some direct time relation- 
ship to the embolic episode were infrequent. Of 60 cases in which films were 
made — those with characteristic clinical picture — findings were entirely 
negative in 11, suggestive in 19, and indicative of some pulmonary disease 
in the remainder {pneumonia, pleural effusion, atelectasis, or carcinoma). 
The roentgen findings in pulmonary embolic disease are entirely nonspecific 
in the usual case and represent the Changes of pulmonary infarction. The 
x-ray diagnosis of pulmonary embolism without infarction is difficult, if not 
impossible, to make. 

Only 19% of patients had any clinical sign which should have brought 
about a diagnosis of deep venous thrombosis. In 34.9% of those patients with 
a positive clinical diagnosis of deep venous thrombosis, a definitive clinical 
diagnosis of pulmonary embolism was made during life. However, only 3.9% 
of all pulmonary emboli were diagnosed in patients not haying an associated 
diagnosis of venous thrombosis. This observation suggests that clinicians are 
reluctant to diagnose the possibility of pulmonary embolism in the absence of 
prior signs in the leg veins. 

The study has shown that at least one patient of every 5 with deep venous 
thrombosis will have a pulmonary embolus. Of all patients with pulmonary 
embolism, the mortality rate is reported as about 18%. 

Knowledge concerning the true location of venojis thrombi capable of 
producing pulmonary embolism is of critical importance in the proper assess- 
ment of the relative value of anticoagulants and vein ligation as therapeutic 
measures. From observations and various reports, surgical ligation of the 
superficial femoral veins does not appear to be basically sound since a large 
percentage of thrombi have been found to occur in locations where such a 
procedure would not have prevented subsequent pulmonary embolism. 

Clinical differentiation of phlebothrombosis from thrombophlebitis on 
the basis of embolic potential is not only valueless but dangerous, contend the 
writers, concurring with opinions of various other clinicians. 

In relation to physical examination of the chest, the authors conclude 
that physical signs, particularly rales, will be present in an appreciable pro- 
portion of patients if the patient is carefully followed with repeated examina- 
tions. No physical sign is considered specific, including friction rub. 



Medical News Letter, Vol. 34, No. 8 



Fortunately, many patients have "premonitory" nonfatal pulmonary 
emboli before the fatal embolic episode. A more vigorous approach to the 
diagnosis and anticoagulant treatment of this group of patients may save many 
from a subsequent fatal embolus. With the present state of knowledge, the 
approach must be an epidemiologic one with serious consideration for a prog- 
ram of active prophylactic therapy in a selected group of patients. 

As described earlier, x-ray examination offers no consistent or specific 
findings to aid in diagnosis, and no other laboratory determination provides 
any reliable criteria for establishing the diagnosis of pulmonary embolism. 
The electrocardiogram is limited, but its value has been underestimated 
because when specific changes are present soon after a probable episode, 
support for the diagnosis is given. 

With the present state of knowledge, treatment of one specific pulmon- 
ary embolic episode is restricted to supportive measures, such as narcotics, 
oxygen, vasopressors, atropine, papaverine, and aminophylline. There is 
no evidence that any of these agents have any effect on ultimate survival. The 
value of anticoagulant therapy is in the possible prevention of subsequent pul- 
monary emboli in a patient whose existing embolus proves to be nonfatal. 
Prevention of secondary infection of a pulmonary infarct is rational and val- 
uable, but has no effect as far as the acute episode is concerned. Similarly, 
it is unlikely that specific operative therapy will play a very useful role. 

The authors believe that anticoagulants have a real place as "prophy- 
lactic" agents in venous thrombosis and nonfatal pulmonary embolism. The 
present tendency in clinical medicine has been to confine anticoagulant therapy 
to patients with clearly established thromboembolic disease. To accomplish 
a greater salvage of patients, the clinician must assume much greater clinical 
awareness of the frequency of thromboembolism and be willing to make a pre- 
sumptive diagnosis and treat with anticoagulants on the basis of suspicion alone. 
(Coon, W. W. , Coller, F. A. , Clinic opathologic Correlation in Thromboembol- 
ism: Surg. Gynec. & Obst. , 109:259-269, September 1959) 

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Eosinophilic Peritonitis 

Eosinophilic infiltration of tissues or organs, for which no causal factor 
can be determined, may occur particularly in association with eosinophilic 
leukocytosis. During the past two decades reports have indicated that eosino- 
philic infiltration of the wall of the gastrointestinal tract may produce severe 
symptoms, often leading to surgical intervention. Various lesions have been 
described — gastroenteritis, peritonitis, and inflammatory fibroid polyp leading 
to intestinal obstruction — and peripheral eosinophilia is not always present. 

During review of 30 cases of eosinophilia of obscure nature seen by the 
authors during the preceding 12 years, it was noted that 10 patients had exper- 
ienced gastrointestinal symptoms. In 3 patients, laparotomy had disclosed 



Medical News Letter, Vol. 34, No. 8 



no gross abnormality that would, account for the symptoms, yet upon micro- 
scopic examination eosinophilic infiltration of the serosa of the duodenum, 
jejunum, or appendix had been found. In addition, one patient with gastro- 
intestinal symptoms associated with leukocytosis but no eosinophilia had been 
encountered in whom laparotomy revealed thickening of the small bowel and 
eosinophilic infiltration of the serosa of the ileum and appendix. 

The cases presented a uniform pathologic picture, but varied clinical 
manifestations. In one case abdominal pain was the sole complaint. Another 
patient suffered abdominal pain, vomiting, diarrhea, one episode of ascites 
with large numbers of eosinophils in the ascitic fluid, and recurrent episodes 
of marked fluid retention requiring the use of diuretics. In another instance, 
abdominal pain, vomiting, and diarrhea were the only symptoms. The symp- 
toms in all 4 patients were episodic with periods of remission varying from 
several weeks to a year or more. 

Although not conclusively established, it was considered that the eosino- 
philic infiltration of the gastrointestinal tract demonstrated in the specimens 
removed at biopsy was responsible for the symptoms. 

No surgical procedure or therapeutic agent was uniformly successful. 
Adrenal steroids were only of short-term benefit when employed. Symptomatic 
and supportive therapy appeared to be of most value in management of these 
patients. 

The presence of necrotizing angiitis of the hypersensitivity type involv- 
ing the serosal vessels suggests that eosinophilic peritonitis may be allergic 
in nature. In one case, definite allergy to certain foods was demonstrated. 
As more exacting immunologic techniques than are now available are devel- 
oped, it may become possible to demonstrate an allergic basis for this entity. 
(Harley, J.B., Glushien, A. S. , Fisher, E. R. , Eosinophilic Peritonitis: 
Ann. Int. Med., 51: 301-308, August 1959) 



Procaine in Intestinal Obstruction and Ileus 



Beginning in early 195 7, the author accumulated evidence from observa- 
tion of many varied cases that convinced him of the effectiveness of procaine 
hydrochloride, introduced into the gastrointestinal tract or into the peritoneal 
cavity, in diagnosing and treating mechanical intestinal obstruction and ileus. 

It appears that this agent directly affects the postganglionic fibers of 
the parasympathetic nervous system which arise from cells situated in, or in 
close proximity to, the innervated organ, resulting in increased tone and 
motility of both the small and large intestine. 

Experimentally, procaine hydrochloride has been injected intraperi- 
toneally, resulting in inexcitability of the splanchnic and vagus nerves and 
allowing peristalsis to occur. 



Medical News Letter, Vol. 34, No. 8 



Also it has been observed that under the influence of procaine hydro- 
chloride there is a relation to the suppression or exclusion of the "slow" 
impulse which was experimentally observed under the chemical stimuli on 
its receptors of the intestines, and the "quick" impulse arising upon stimula- 
tion of the Vater Pacinian corpuscles. 

A speculative generalization has led some to speak of the activities of 
the sympathetic divisions as catabolic and the parasympathetic divisions as 
anabolic. 

In the cases presented," doses of 2 to 10 ml. of 1 or 2% procaine hydro- 
chloride were introduced into the alimentary canal by means of a Levine 
tube, through a cecostomy opening, or directly into the peritoneal cavity by 
means of an abdominal catheter. Occasionally, prostigmine was used. 

From results described, it would appear that the technique can be used 
as a diagnostic sign in differentiating between intestinal obstruction and ileus. 
If motility, including peristalsis, is initiated within seconds to minutes, 
maintains or increases its tones, or disappears yet recurs with additional 
introduction of the agent, it may be concluded that surgical intervention is 
not required immediately. It is assumed that there is temporary inhibition of 
the peristalsis of myogenic or neurogenic origin. 

Injected immediately after a gastrointestinal operation or secondary to 
an earlier operation in an attempt to initiate early intestinal motility, pro- 
caine hydrochloride has been used with success. Postoperative alimentation 
may be established much earlier with this procedure than without it. 

Prognosis of intestinal activity can be determined early by this means, 
obviating the need for operation in some instances, or establishing the need 
for surgery in others. Therapeutically, peristalsis can be initiated earlier 
in the management of ileus due to either intrinsic or extrinsic factors. 
(Frankel, L. A. , Mechanical Intestinal Obstruction and Ileus: Use of Procaine 
Hydrochloride in Differential Diagnosis and as a Therapeutic Agent: J. Internat, 
Coll. Surg., 32: 135-142, August 1959) 



Results in Abdominal Aortic Homograft Replacement 

Patients with aneurysm of the abdominal aorta should be advised to 
have resection of this lesion if (1) operative mortality is low, and (2) chance 
for long-term survival is enhanced. The authors studied the results of 110 
patients with abdominal aortic aneurysms who underwent surgical exploration 
and replacement with homograft in an attempt to provide justification for these 
qualifications, All cases occurred during the 4-year period following May 
1953; none received replacement with synthetic materials. Study relative to 
the use of synthetic materials will be later, due to their relatively recent 
introduction. 



Medical News Letter, Vol. 34, No. 



Of the total group of 110 patients who had excision and homograft re- 
placement of abdominal aortic aneurysms, 104 came to surgery with intact 
aorta. Of that group, there were 15 deaths with a mortality rate of 14. 4%. 
Three patients with rupture of the aneurysm died before leaving the hospital. 

Of the 18 hospital deaths, 8 (44%) were due to postoperative hemorrhage 
related to the homograft, 5 being due to rupture of some portion of the wall, 
and 3 showed hemorrhage from the suture lines. Among the 7 hospital deaths 
resulting from causes not related to the graft, 2 were not autopsied, 2 died 
from renal failure, gangrene of the intestine occurred in 2, and one developed 
myocardial infarction in the third postoperative week. 

Follow-up of the 91 patients who left the hospital disclosed a total of 8 
late deaths over the 4-year period considered. Failure of the homografts 
accounted for 3, one occurred two and one-half years later, and 2 developed 
one and one -half years later. In the other 5 cases, the grafts were found to be 
secure and patent. There were no late deaths among the 3 patients with rup- 
tured aneurysm who survived emergency operations. 

The incidence of early operative deaths following elective resection and 
graft replacement of abdominal aortic aneurysms, as reported in most series, 
ranges from 10 to 20%. Judging from the results of the present series, it would 
appear that after the patient leaves the hospital his chance of survival approx- 
imates that of the normal population age comparable to that estimated for the 
group studied. 

A surprising and important finding in the review of both early and late 
deaths in the present series has been the number of deaths resulting from 
complications in the homograft. Because of this experience, cloth prostheses 
have been adopted exclusively for aortic replacement in the clinic of the study 
and may prove advantageous in avoiding the problem of graft failure encountered 
with homografts. 

It is of interest that all of the 3 grafting failures which caused late deaths 
presented as severe gastrointestinal hemorrhage, false aneurysms having 
formed and ruptured into the retroperitoneal duodenum. (Sheranian, L. O. , 
Edwards, J. E. , Kirklin, J, W. , Late Results in 110 Patients with Abdominal 
Aortic Aneurysm Treated by Re sectional Placement of Aortic Homograft: 
Surg. Gynec. & Obst. , 109: 309-314, September 1959) 



tA- »** *>+ 






Change of Address 

Please forward requests for change of address for the News Letter to: 
Commanding Officer, U. S. Naval Medical School, National Naval Medical 
Center, Bethesda 14, Md. , giving full name, rank, corps, and old and new 
addresses. 



Medical News Letter, Vol. 34, No. 8 



Roentgen Changes in Sickle Cell Anemia 

Sickle cell anemia is almost exclusively limited to the Negro race. Its 
manifestations are diffuse so that no tissue or viscus is spared from its in- 
volvement in the human host. The condition is of interest particularly to 
physicians practicing in the south where the concentration of the disease is 
at its highest. The current report is an analysis of the clinical and roent- 
genologic aspects of 16 case studies. 

Cardiac enlargement was the most common finding. This was general- 
ized and, if associated with a prominent outflow tract, rheumatic heart dis- 
ease was often erroneously assumed to be present. Not infrequently, various 
pleuropulmonary densities were identified, compatible with pneumonitis, 
infarct, or linear' atelectasis. A slightly elevated hemidiaphragm suggestive 
of hepatomegaly was also seen. 

In examination of the abdominal region, small bowel ileus was a frequent 
finding. Lienohepatomegaly and cholelithiasis were observed as concomitant 
occurrences. 

A fairly diffuse granular appearance was identified throughout the cal- 
varium. This impression was chiefly gained from the mottled porosity of 
the diploic architecture. In the other peripheral bones, osseous changes 
were variable. In the order of importance they were: {1) generalized change 
in bone architecture — irregularity of endosteum, diffuse porosis, faint linear 
or oblique dense bands, localized zones or radiolucency, or sclerosis; (2) 
growth arrest lines; (3) periosteal elevation; (4) disturbed cortex medullary 
ratio; and (5) in small bones, diffuse porosis in sharp contrast to the disturbed 
pattern of residual striae. 

In the joints, epiphysitis and aseptic necrosis were not infrequent find- 
ings. This was particularly true of the hip as a weight bearing joint, result- 
ing in coxa plana. The vertebrae presented reduction of height and broadening 
of transverse diameter with biconcave plate impressions. 

All of the patients had an anemia with an average red blood cell count 
of 2, 2 million /cubic mm. and an average hemoglobin of 65%. There was no 
relationship between the degree of anemia and severity of clinical symptoms. 
The typical clinical course is that of alternate periods of remission and 
recrudescence. With progression and worsening of the patient's general state, 
a typical crisis may be expected. At the peak of one of these violent cyclic 
attacks, the patient may experience pain anywhere in the body, mimicking 
almost any clinical syndrome. This leads to various roentgen examinations 
and cooperative efforts with the clinician for diagnosis. The dictum, "to 
think of sickle cell anemia is to diagnose it, " certainly holds true. 

In a sickling crisis, erythrocytolysis becomes acute, and is associated 
with leukocytosis, fever, pain, and cardiac insufficiency. When abdominal 
pain is severe and an adynamic ileus is visualized, the erroneous diagnosis of 
an acute emergent abdomen may be made. Frequently, a crisis is precipitated 



Medical News Letter, Vol. 34, No. 



by pneumonitis. Occasionally, it is difficult to distinguish pneumonitis from 
atelectasis or pulmonary infarction. Arterial thromboses are the cause of 
these varied pleuropulmonary densities, as well as the bizarre bone densities 
and epiphyseal osteochondritis. 

The differential diagnosis includes almost the entire gamut of the syn- 
dromes of clinical medicine, principal among which are: (1) osteochondritis; 
(2) anemia, Cooley's type or hemolytic erythroblastic; (3) hypothyroidism, 
cretinism, or Cushing's syndrome; (4) Gaucher's or caisson disease; (5) leu- 
kemia, hemangioma, or osteomyelitis; (6) xanthomatosis, neurofibromatosis, 
senile osteoporosis; (7) chondrodystrophia or lues; and (8) rheumatic disease. 
(Deibert, K. R. , Roentgen Changes in Sickle Cell Anemia: Am. J. Roentgenol. , 
82 : 501-504, September 1959) 

sjs * * * * * 



Course and Prognosis of Histoplasmosis 

Prior to 1935 histoplasmosis was diagnosed solely by the pathologist 
at postmortem examination. Since then an increasing number of nonfatal 
cases have been described. In 1945 Christie and Peterson first demon- 
strated that the distribution of histoplasmin sensitivity correlates closely 
with geographical areas having a high incidence of nontuberculous pulmonary 
calcifications. Surveys of histoplasmin skin sensitivity in various parts of 
the United States have shown that a benign form of histoplasmosis is common 
in certain endemic areas and accounts for the overwhelming majority of all 
Histoplasma infections. It has been estimated that 30 million people in the 
United States are infected with H. capsulatum. The spectrum of illness 
varies from asymptomatic infection with residual skin test sensitivity to 
disseminated fatal disease. The frequency of each clinical variety is not 
known, although mild respiratory illness due to primary infection is probably 
common in the endemic area. 

In 1948 the chronic pulmonary form of histoplasmosis was described. 
Since that time this form of the disease has been reported more frequently, 
Interest in this manifestation of the disease has increased because chronic 
pulmonary histoplasmosis is clinically and radiographically indistinguishable 
from reinfection type pulmonary tuberculosis. The prevalence of chronic 
pulmonary histoplasmosis in tuberculosis sanatoriums in endemic areas has 
been estimated at 10%. 

The present report is an analysis of thi3 disease on the basis of 123 
culturally proved cases of different clinical varieties. 

Acute pulmonary histoplasmosis is almost invariably a benign infection, 
only rarely going on to more progressive disease. The present series con- 
tains 8 such cases, 7 being of the "epidemic" variety. The latter cases are 



10 Medical News Letter, Vol. 34, No. 8 



usually associated with a "point source" of infection — usually unused, cnicucu. 
coops or caves, and damp shaded areas of soil. The clinical severity of this 
type of infection correlates well with the time and intensity of exposure to the 
point source. Seven of the 8 cases of that type in this series were of this 
severe form with all patients being alive after follow-up periods averaging 
3 years. 

Initial cultural diagnoses were made from sputum in 3 cases, gastric 
washing aspirate in 3, and from pleural fluid and tonsil tissue in one each. None 
of 15 blood cultures and 3 bone marrow cultures from 5 patients were positive. 
Histoplasmin skin tests were positive in 6 of the 8 patients. Only one had a 
positive reaction to the tuberculin skin test, as well as the histoplasmin skin 
test. Complement fixation tests were positive during acute illness in all. 
Titers ranged from 1: 8 to 1: 64. In 3 patients serologic tests were persistently 
positive for more than one year after the acute clinical episode had subsided. 

The duration of clinical illness ranged from 19 days to 3 months. Fever 
was present in all cases. The predominant symptoms were cough, chest pain, 
chills, sweats, and dyspnea. Physical findings were scant. White blood cell 
counts ranged between 8, 000 and 14, 000 cells per cu. mm. In 7 patients 
chest roentgenograms showed diffuse nodular densities; in the eighth there 
was local and pneumonic infiltration. Two patients with diffuse nodular lesions 
showed complete clearing in roentgenograms taken 8 months and 2 years after 
the initial examination; all others continue to show nodular densities and cal- 
cifications. 

Demonstration of calcifications in liver and spleen of patients with 
inactive histoplasmosis supports the concept of blood-borne dissemination 
at the time of the primary infection. The overwhelming majority of patients 
show no evidence of this primary dissemination beyond residual histoplasmin 
sensitivity and healed calcifications. 

Disseminated cases of histoplasmosis were the first clinical type to be 
recognized and, since all the earliest cases described were fatal, it was 
assumed that this disease was uniformly fatal. All of the 25 cases in this 
series demonstrated clinical evidence of systemic dissemination to other 
organs — liver, spleen, mucous membrane, and adrenal glands. Only 6 
patients survived, 3 having been treated with amphotericin B. 

Blood was the most frequent source of culturally positive material 
from which the diagnosis was first made during life; next in order was sputum, 
then material from gastric washings. Three cases were diagnosed initially 
by cultures of biopsy specimens of tissues obtained from oral, laryngeal, and 
lingual ulcers. Positive reaction to skin tests was shown by 14 of the 25 
patients; only 11 reacted to histoplasmin. This observation possibly is a re- 
flection of the clinical severity of the disease, with resulting anergy. Results 
of complement fixation tests were positive in 14 of the 23 patients in whom 
they were performed. 

The most common symptom in this group was fever, occurring in al 1 
with weight loss, cough, chills, fatigue, weakness, and anorexia occurring 



Medical News Letter, Vol. 34, No. 8 11 



in this order of frequency. A palpable liver and spleen were evident in 17 
patients. White blood cell counts and hemoglobin determinations were within 
the normal range in more than one -half of the cases. Chest roentgenograms 
were normal in 7 patients, 9 showed diffuse nodular infiltrates in both lung 
fields, 7 demonstrated discrete pneumonic infiltrations, and 2 had cavitary 
disease. 

When dissemination from the lungs occurs the organs most frequently 
involved are those containing large numbers of reticuloendothelial cells — 
spleen, liver, and lymph nodes. Adrenal involvement is common, with 20% 
in this series showing Addison's disease, Four patients with this complica- 
tion died and the one survivor continues to be maintained on 5 mg, of pred- 
nisone daily. Present experience and that quoted in literature indicate that 
mucocutaneous lesions usually indicate disseminated disease, although they 
may be the only lesions insofar as can be determined. Such cases may have 
a prolonged course with poor prognosis. 

The largest number of cases included in this analysis are of the chronic 
pulmonary variety — 90 patients. The majority were hospitalized in a tuber- 
culosis sanatorium at some time during the course of their illness. The disease 
was fatal in 16, pulmonary disease was responsible for death in 9, while 4 died 
following pulmonary surgery. The average duration of illness was 69 months. 
Initial cultural diagnosis was made from sputum in 79 cases, lung tissue 
in 7, fluid from bronchial washings in 3, and material from gastric washings 
in one case. Reactions to histoplasmin skin tests were negative in 20% of the 
90 culturally proved cases. Reactions to tuberculin skin tests were positive 
in 41%. These findings do not detract from the value of the histoplasmin skin 
test as a clinical and epidemiologic tool, but they do indicate that a negative 
result of a skin test does not rule out the diagnosis. Complement fixation 
tests were positive in 79 patients (91%). 

The clinical picture is that of a chronic pulmonary infection indistinguish- 
able from any other, including tuberculosis. Cough, weight loss, dyspnea, 
and fever were the most frequently occurring symptoms, with chest pain and 
hemoptysis occurring in nearly one -half of the patients. Significant physical 
findings in this group also were infrequent. Of the laboratory studies, only 
the sedimentation rate was consistently elevated — 93% showing values above 
10 mm. per hour. 

Chest films revealed cavities in 78 (87%) of the 90 patients, located in 
the apex or subapex in 77 patients. Of this group 28% presented bilateral 
cavities, and 38% had multiple cavities in the upper lobe. Of this group 87 
were followed by x-ray, 43 showed x-ray progression, 43 remained stationary, 
and only one showed improvement. The percentage showing x-ray progression 
was directly proportional to the length of time of follow-up. 

Late stage developments of the chronic form of this disease include 
bronchiectasis, probably incident to bronchial obstruction. Seven of this series 
showed this development. Six patients developed emphysema and 2 developed 
bronchopleural fistula and empyema. 



12 Medical News Letter, Vol. 34, No. 8 



Some descriptions of this chronic pulmonary form of the disease have 
stressed its progressive nature. Another concluded that "the course is benign 
and is not altered by medical therapy. " The present analysis clearly illus- 
trates the progressive nature of this disease, although many may show vary- 
ing periods of clinical remission. With recent advances in therapy of the 
deep mycoses, these patients need not be consigned to a progressively 
debilitating downhill course. (Rubin, H. , et al. , The Course and Prognosis 
of Histoplasmosis: Am. J. Med., XXVII : 278-288, August 1959) 

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Role of Kidney in Heart Failure 

The efficacy of treatment of congestive heart failure has surpassed 
knowledge of its pathologic physiology. Useful lives have been prolonged 
despite only fragmentary information concerning mechanisms responsible 
for the symptoms of the disease, or mechanisms of action of therapeutic 
regimens and agents employed. 

The effectiveness of newer diuretic agents has led to a preoccupation 
with the role of the kidney in fluid retention. However, this preoccupation 
with the late stages of the disease, and with the role of the kidney in produc- 
tion of edema in congestive heart failure, has tended to obscure the evidence 
that changes in sodium and water metabolism are present in heart disease at 
a time when the cardiovascular system is only slightly impaired. The study 
of sequential alterations in function in the natural progressive course of the 
syndrome would help differentiate the primary changes from secondary abnor- 
malities, and determine whether the changes in sodium metabolism are part 
of a compensatory process or merely the deleterious effects of circulatory 
insufficiency. 

In producing anatomical disease in dogs similar to those observed in 
human beings, the authors have attempted to define some steps in the devel- 
opment of the manifest physiologic changes in congestive heart failure: 
Although gross clinical evidence of sodium retention is first noted in the dog 
with frank failure, slight but definite alterations in sodium excretion can be 
detected even with the mildest of these valvular lesions — pulmonary insuf- 
ficiency. Incident to slight change, decrease in sodium excretion is noted in 
an animal with normal venous pressure and normal basal glomerular filtra- 
tion rate. Such evidence suggests that alterations in peak capacity for sodium 
excretion may be a far earlier concomitant of cardiac impairment than is 
now supposed. Increasing the severity of cardiac damage produces a pro- 
gressive decrement in the rate of sodium excretion following saline infusion. 
Up to a point, despite reduced ability to excrete a sodium load and an in- 
creased total exchangeable sodium, ascites and edema do not develop. More- 
over, the basal glomerular filtration rate may be normal even in the animal 



Medical News Letter, Vol. 34, No. 8 i3 



with frank congestive failure. This fact suggests that increased tubular reab- 
sorption of sodium is a significant factor. 

Following the work of Merrill in 1946, emphasis was placed on the role 
of the reduced glomerular filtration rate in the pathogenesis of sodium reten- 
tion of congestive heart failure. Other reports soon indicated that filtration 
rate was not invariably reduced in patients with heart failure and that clinical 
improvement may occur without rise in filtration rate. Recently, attention has 
been focused on the salt -retaining hormone of adrenal cortical extract — aldos- 
terone. Here again, consistency of effects is lacking as it has not been shown 
that urinary aldosterone is elevated in all edematous patients. Although the 
mineralocorticoids have long been known to play an important role in main- 
tenance of normal sodium balance, the direct renal effect of the steroids has 
not been shown. 

Speculation has long existed concerning the possible role of renal nerves 
in alterations of renal function in congestive heart failure. The function of 
renal nerves, however, is a confusing area of renal physiology. Most evidence 
to date minimizes their importance in control of renal function. However, the 
authors' experiments seem to indicate that some mechanism of control by 
renal nerves influences blood flow, filtration rate, and electrolyte interchange. 

Demonstration of increased sympatho- adrenal activity on the kidney in 
valvular heart disease raises the question of the nature of the initiating mech- 
anism. Sodium retention is found in a number of diverse conditions in which 
there is a reduction in effective circulating blood volume and a tendency toward 
a decrease in arterial pressure. Under such conditions carotid sinus activity 
is decreased, leading to reflex vasoconstriction and restoration of blood pres- 
sure. Experiments in various laboratories yield observations which offer 
evidence for the possible role of the carotid sinus as the receptor organ 
initiating the reflex increase of sympatho -adrenal tone in the kidney in con- 
gestive heart failure. Ultimately, it is hoped to be able to demonstrate pro- 
gressive decline in rate of discharge of baroreceptors of the carotid sinus as 
an animal is followed through the various stages of cardiac impairment to 
frank failure. 

If there is a progresssive decrease in rate of discharge from the carotid 
sinus with progressive impairment of cardiac function, then a common recep- 
tor mechanism may be responsible for both the increased sympathetic activity 
and for hypersecretion of aldosterone. Thus, the carotid sinus may regulate 
mineralocorticoid activity of the adrenal gland as well as sympatho -medullary 
function. Undoubtedly, other mechanisms play a role in the normal regulation 
of sodium balance and the sodium retention of congestive heart failure. Further 
work may help to elucidate the interrelationship of these factors in congestive 
heart failure and other forms of circulatory stress. {Barger, A. C. , 
Muldowney, F. P. s Liebowitz, M. R. , Role of the Kidney in the Pathogenesis 
of Congestive Heart Failure: Crculation 3 XX: 273-285, August 1959) 

ife jflf iflC jflf jft 3JE 



14 Medical News Letter, Vol. 34, No. 8 



Diagnostic Test for Hyperthyroidism . 

At the beginning of the present century a keen interest developed in 
the physiologic properties of the recently discovered hormones of the adrenal 
medulla and thyroid. Concepts that potentiation by thyroid hormones of the 
physiologic effects of epinephrine, and existence of interrelationships of the 
adrenal medulla, sympathetic nervous system, and thyroid developed. In 
1918 a diagnostic test for hyperthyroidism based on these relationships was 
proposed. Following injection of epinephrine, an increase in heart rate, 
rise in blood pressure, and development of tremor and palpitations indicated 
the presence of hyperthyroidism. However, alarming reactions were ob- 
served frequently with the result that the test was considered to be unsatis- 
factory and soon became unpopular. 

Ample proof exists that hemodynamic and metabolic responses to 
epinephrine are strikingly altered by variations in the levels of the thyroid 
hormones. Data accumulated by the authors have proved that potentiation of 
action of the catechol amines is not due to the increased metabolic rate which 
is an almost constant feature of hyperthyroidism. All known facts strongly 
suggest that the concentration of the circulating thyroid hormone controls the 
response to both epinephrine and norepinephrine. At the same time thyroid 
hormone is not the only hormone which conditions physiologic response to 
these agents. The presence of adrenal steroids is known to be necessary 
for the proper action of the catechol amines. The site of interaction, as well 
as the exact chemical relationship, has not been satisfactorily defined. 

Recent emphasis in the diagnosis of hyperthyroidism has been on tests 
utilizing the uptake of radioactive iodine by the thyroid gland or the level of 
serum protein-bound iodine, while the basal metabolic rate has fallen into 
disuse. The accuracy of the former two tests exceeds that of the latter, but 
in addition to expense, they too are subject to certain features of unreliability. 
For these reasons it is not unusual for the clinician to have occasional dif- 
ficulty in resolving the diagnosis of thyrotoxicosis. 

Another determination of thyroid function which can operate in the face 
of the difficulties with other tests should be welcome. For this purpose, 
response to epinephrine can be used. Demonstrated in the work of this report, 
changes in both oxygen consumption and hemodynamics can be used to separate 
hyperthyroid from euthyroid persons. A sharp separation of these two groups 
can be achieved by the change in the product of heart rate and pulse pressure 
to an infusion rate of epinephrine of 0. 05 ug/kg. /minute. This dosage of epine- 
phrine was selected after observation of eifects of serial dilutions because it 
was found capable of producing significant changes in oxygen consumption, 
heart rate, and blood pressure of thyrotoxic patients without being likely to 
produce disturbing symptoms. Caution is necessary, for thyroid storm and 
fatal disturbances in cardiac rhythm have been precipitated by epinephrine. 

The authors contend that the epinephrine test is simple to perform, 
provides a high degree of specificity in distinguishing hyperthyroidism, and 



Medical News Letter, Vol. 34, No. 8 15 



should be useful in clinical practice, (Murray, J. F. , Kelly, J.J. Jr., The 
Relation of Thyroidal Hormone Level to Epinephrine Response - A Diagnostic 
Test for Hyperthyroidism: Ann. Int. Med., 51: 309-321, August 1959) 

$ $ $ $ $ $ 

.Alcoholism and the Medical Profession 

Alcoholism has been known and recognized as an illness for many years. 
In the remote past, as well as more recently, a number of physicians have 
recognized this illness as a medical problem. Until comparatively recently, 
however, the organized profession has done very little about it. The attitude 
of medical organizations might have been due to the influence of the general 
public which looked upon alcoholism more as a moral problem than a medical 
one. 

Although not the first to hold this view, the Commissioner of Health of 
Buffalo at the turn of the century addressed the City Council on the problem 
of excessive drinking and stated his opinion that it was an illness and not a 
crime to be an alcoholic. He recommended that jail sentences meted out to 
correct the problem be changed to hospitalization so that alcoholics could get 
medical care and proper rehabilitation. However, his words fell on disinter- 
ested ears. 

Not until 1948 were any real steps at organized effort achieved to educate 
the public and the medical profession. The impetus was initiated in the County 
Medical Society of Erie County, N. Y. , with the American Medical Association 
entering the picture in 1950. Since then, although with a slow beginning, great- 
er and greater mementum has been built up. At present, the Committee on 
Alcoholism of the Council on Mental Health of the American Medical Assoc- 
iation of which the author is the Chairman is making great strides in evalua- 
tion of the situation throughout the country. This includes education of phys- 
icians, nurses, medical school deans, hospital administrators, hospital 
insurance officials, and all possible agents involved directiy or indirectly in 
the attack on the problem of chronic alcoholism. 

The individual physician must recognize his responsibility in his own 
community to the patient suffering from alcoholism. He can no longer avoid 
the issue. He can no longer neglect these patients. He cannot "pass the buck. " 
He must treat them. There is sufficient evidence that good results can be 
obtained. Cures cannot be promised since a cure would imply that the patient 
might be able to drink normally again. However, complete recovery can be 
attained by tlie patient with the help of his physician. To this end the doctor 
must work. Properly trained in the medical approach and with sufficient 
psychiatric orientation, very satisfactory results can be obtained with most 
patients. It must be recognized that there is no specific routine for this dis- 
ease. There is no antibiotic or chemical miracle drug which will do away 
with the illness. 



16 Medical News Letter, Vol. 34, No. 8 



The physician must spend sufficient time with his patient. Ke must 
not only rehabilitate him physically, but must help him to mature emotion- 
ally. The physician must study this disease as he does other diseases, its 
etiologic factors, background, and history. He must make definite eval- 
uations and pursue therapeutic programs with thoroughness and understanding. 
If postgraduate courses on this disease are not available in any specific area, 
the Committee on Alcoholism stands ready to help in this matter, working 
through local associations. 

As with other diseases, the answer to this problem lies in prevention 
rather than in therapy. By instituting proper prophylactic measures and 
by careful advice, many cases of alcoholism can be prevented. It is never 
too early to detect signs of impending or incipient alcoholism. Constant 
awareness of the problem is mandatory. 

In addition to the practicing physician, other medical agencies must 
be used in combating the problem of alcoholism. The general hospital should 
accept these patients as sick people who deserve and require attention. Acute 
alcoholic intoxication can be, and often is, a medical emergency. Hospital 
personnel should be properly instructed not only in medical and psychiatric 
therapies for this disease, but also in the proper attitude to be adopted 
toward such patients. The correct approach toward any sick person is a 
great step toward helping him, and the attitude of the therapist is a tremen- 
dous step toward acceptance by the patient of the help he requires. 

The physician, the nurse, and members of related professions must 
remember that they also are citizens and as such must take an interest in 
their communities. Sufficient interest must be taken in the problem to 
engage in efforts for education in relation to the facts of alcoholism with lay 
groups as well as professional groups. Both physicians and nurses can carry 
the message of sympathy and understanding to these patients. They can help 
them get the kind of assistance they need and refer them to available re- 
sources for such help. 

When all possible facilities are brought to bear by the physician and 
the ancillary professions, and there is sufficient understanding of the prob- 
lem by these people, interest can be stimulated toward gaining more know- 
ledge. As with many medical problems in the past, increased research 
and knowledge will eventually lead to the answers. (Block, M. A. , Alcoholism 
and the Medical Profession: Am. J. Pub. Health, 49-: 1017-1024, August 1959) 

Use of funds for printing this publication has been approved by the 
Director of the Bureau of the Budget, 19 June 1958. 

$ Jjt * Sjt $ * 



Medical News Letter, Vol. 34, No. 8 17 



IN MEMORIAM 

May 1959 
LT Edward H. Kershner MSC USN (Ret) 9 

July 1959 
LT JG William A. Thornton MSC USN (Ret) 14 

August 1959 
LCDR Albion C. Tollinger DC USN (Ret) 12 

CDR Loretta (n) Lambert NC USN (Ret) 17 

September 1959 
CAPT Dunne W. Kir by MC USN 7 

CAPT Robert L. Wagner MC USN 7 

CAPT Lesley Leak MSC USN (Ret) 9 

CAPT John B. Farrior MC USN (Ret) lfr 

CAPT George N. Raines MC USN (Ret) 16 

CAPT Trenton K. Ruebush MSC USN 26 

LT Sidney W. Bond MSC USN (Ret) 30 



October 1959 



CAPT Ramon O. Mickell DC USN 



$ $ * 



Navy Medical Department Participation 
in Professional Meetings 

Armed Services Orthopedic Seminar 

The first Armed Services Orthopedic Seminar was held at the U. S. Naval 
Hospital, Oakland, Calif. , 23-25 September 1959, with some 300 Medical 
officers of the Army, Navy, and Air Force, and their civilian consultants 
attending. 

Exhibits of the latest Navy-developed prosthetic limbs, a resume of 
the research program of bone adhesive developed at the Prosthetic Research 
Laboratory, and a demonstration of artificial kidney with discussion of renal 
shut-down as a complication in the orthopedic patient were presented during 
the first day. Subsequent sessions were devoted to military orthopedic train- 
ing, symposium on knee injuries, orthopedic research, cervical spine in- 
juries, stereo-anatomy of the hand, and reconstructive surgery of the hand. 

American College of Surgeons Convention 

The Naval Medical Research Institute, National Naval Medical Center, 
Bethesda, Md. , presented two scientific exhibits and a surgical forum paper 
at the American College of Surgeons convention at Atlantic City, N.J. , 
29 September to 2 October 1959. 



18 Medical News Letter, Vol. 34, No. 8 



The exhibits demonstrated two techniques developed in the Experimental 
Surgery Branch of the Research Institute which have become clinically applied 
at the Naval Hospital, Bethesda. The Instrumentation Division of the Institute 
collaborated in the design and production of much of the electronic equipment, 
and the Naval Research Laboratory assisted in the design and construction of 
the apparatus. 

One exhibit was a working model of the heart-lung machine and temper- 
ature regulator which enables the viewer to control the temperature of the 
circulating fluid. Descriptive material was presented which showed the tem- 
perature chart of an experimental animal whose body temperature was lowered 
from 37°C. to 7° C. in 10 minutes. 

The other exhibit pertained to a diagnostic procedure designed to visual- 
ize the coronary arteries. In order to discover the location and operability of 
coronary artery atherosclerosis, a radio-opaque dye is injected via a catheter 
placed in the aorta. An electronically powered apparatus then injects the dye 
during the period of maximal coronary artery filling and exposes the x-ray 
film before the next cardiac contraction. Coronary arteriograms employing 
this technique have been performed clinically in collaboration with the Depart- 
ment of Cardiology at the Bethesda Navy Hospital. 

At the Surgical Forum a paper entitled "Differential Hypothermic Cardio- 
plegia" was presented by Dr. H. C. Urschel and LT J. J. Greenberg MC USN. 
Their discussion described how cooling to temperatures below 16° C. enables 
the heart to be stopped for extended periods of time and allows the surgeon to 
operate in a bloodless and motionless field. This method, devised in the 
surgical research laboratory, has since been used successfully in several 
open heart procedures at the hospital. 

American Society of Clinical Pathologists 

At the meeting of the American Society of Clinical Pathologists in 
Chicago, 111. , during September 1959, several members of the staff of the 
Naval Medical School, National Naval Medical Center, Bethesda, Md. , par- 
ticipated. LT T.C. Hartney MC USN, CDRR.M. Dimmette MC USN, and 
CAPT J.S. Shaver MC USN presented a paper, "No Major Reactions and Few 
Minor Reactions in 15,449 Blood Transfusions. " CDR Dimmette, with 
LCDRJ. E. Szakacs MC USN and CDR E. C. Coward, Jr. MC USN, presented 
a paper dealing with the pathology of catecholamines. LT F. W. Sunderman, Jr. 
MC USNR discussed "Causes for Discrepancies in Electrophoretic Fraction- 
ation of Serum Proteins. " During the meeting CDR Dimmette was elected to 
the Council on Microbiology of the Society for a period of 3 years. 

International College of Surgeons 

The degree of Honorary Fellow of the International College of Sui eons 
was presented to RADM Bartholomew W. Hogan, Surgeon General of the Navy, 
during the 24th Annual Congress of the North American Federation of the 



Medical News Letter, Vol. 34, No. 8 19 



College in September 1959. At one of the sessions RADM Hogan was moderator 
for a symposium presented by Navy physicians — "Medical Operations and 
Research in Climatic and Environmental Extremes. " 

Association of Military Surgeons 

CAPT Ruth A Houghton NC USN, Director, Nursing Division, Bureau 
of Medicine and Surgery, and current Chairman of the Nurse Corps section 
of the Association of Military Surgeons, will greet the section meeting on 
Monday, 9 November 1959. At this session CDR Mary C. Grimes NC USN, 
Head, Nurse Corps Reserve Liaison Branch of the Bureau, will preside. The 
program will consist of a symposium, "Ten Years of Progress, " during which 
LT Hope Mclntyre NC USNR will discuss ' Improving Teaching Methods Provides 
Better Patient Care. " Other details of Medical Department participation in the 
convention program appeared in the Medical News Letter of 4 September 1959. 



Volunteers Invited for Operation 
" Deep Freeze — 61 " 

RADM B. W. Hogan, Surgeon General of the Navy, has announced that 
regular and experienced Reserve Medical Corps officer volunteers will be 
needed to man the important Antarctic South Pole, Byrd, Hallet, and McMurdo 
Sound (Flight Surgeon) Bases for Operation "Deep Freeze — 61. " In April I960, 
the volunteers selected will begin 7 to 8 months training in phases of medical 
practice particularly applicable to these stations, including: traumatic and 
general surgery; anesthesiology; otolaryngology; emergency dental care; cold 
weather medicine, hygiene, and sanitation; and polar air, ice, and water 
safety and survival. 

Because the Medical Officer at Pole, Byrd, and Hallet Base is also the 
Officer -in-Charge of the station, selectees will receive training in Naval 
Jurisprudence, communications, administration, morale functions, andlead- 
der ship. 

Upon completion of training in the fall of I960, the Medical officers will 
fly from Davisville, R. I. to Antarctica via Honolulu, Canton, Fiji, and New 
Zealand and will spend approximately one year on the ice at a base with fif- 
teen to twenty men. 

It is considered that this assignment presents an opportunity to an inter- 
ested and suitable Medical officer to round out medical training, to save money, 
to participate in an interesting research program — biological, medical, and 
geophysical; and to become acquainted with the world's last frontier. 

Applicants for this assignment will address letters of request, via com- 
manding officer when applicable, to the Bureau of Medicine and Surgery, 
Code 31, Department of the Navy, Washington 25, D. C. 



20 Medical News Letter, Vol 34, No. 8 



Courses in Medical Aspects of Missile Operations 

Three classes in Medical Aspects of Missile Operations will be held at 
the 6550th U.S. Air Force Hospital, Patrick Air Force Base, Fla. , during 
Fiscal Year I960. The presentation features instruction in occupational health 
and toxicologic problems of missile weapons systems. 

Class No. Class Dates Deadline for Requests 

7 11-21 Jan I960 30 Nov 1959 

8 14-24 Mar I960 1 Feb I960 

9 9-19 May 1960 28 Mar I960 

The Navy has been allotted a quota of three members for each course. 
Applications are encouraged from either Medical Corps or Medical Service 
Corps officers, particularly those officers whose duties are with missile 
organizations ashore or afloat. Reserve officers will be considered, selection 
depending on the length of active duty remaining on present service agreement. 

Secret security clearance is required on all candidates approved for 
attendance and must be so indicated on the official request. 

Officers desiring to attend one of the courses should submit a written 
request to the Bureau of Medicine and Surgery via their commanding officer. 
Requests must be received in the Bureau by the dates indicated for each course. 

Successful candidates will be issued Temporary Additional Duty travel 
and per diem orders from BuMed training funds. 

****** 

BUMED INSTRUCTION 6700. IB 31 August 1959 

From: Chief, Bureau of Medicine and Surgery 

To: Ships and Stations Having Medical /Dental Personnel 

Subj: Medical and dental equipment; maintenance and repair program 

The purpose of this instruction is to provide information concerning the em- 
ployment of Medical Repairmen (MRM) and Dental Repairmen (DRM), and 
furnishes instructions relative to the procurement of repair parts and tools. 

****** 

BUMED INSTRUCTION 5512. 2 1 September 1959 

From: Chief, Bureau of Medicine and Surgery 

To: Medical Centers, U.S. Naval Hospitals, U.S. Naval Dispensaries, 

and Activities Having Station Hospitals 



Medical News Letter, Vol. 34, No. 8 Zl 



Subj: Name-Plate identification for Medical Department personnel; 
wearing of 

The purpose of this instruction is the notification of requirement for all 
Military Medical Department personnel and all civilian employees who come 
in contact with patients or the public to wear name badges while performing 
their duties. 

V 1 * vj* %l* *JU *\m «1* 

T T T 'i* "P T 

Recent Research Reports 

Naval Medical R search Institute, NNMC, Bethesda, Md. 

1. Inhibition by Acetylsalicylic Acid of Rickettsial Strains Resistant to 
p-aminobenzoic Acid. NM 52 05 00.02.03, 1 May 1959. 

2. Indirect Estimation of Body Surface Area and Volume. NM 31 01 00.01.01, 
6 May 1959. 

3. Pharmacological Studies on Irradiated Animals. VII. Protection of Guinea 
Pigs Against Radiation-Induced Mortality by Cell -Free Mouse Spleen Extract 
Stored for One Year. NM 62 04 00. 03. 02, 8 May 1959. 

4. Enzymatic Studies on the Gelatin-Collagen-Food Transition. NM 01 01 00 
.02. 09, 15 May 1959. 

5. The Use of Small Laboratory Animals in Medical Radiation Biology. 

VI. Lethal Effect of Co 60 Gamma Rays in Mice. NM 62 02 00. 01. 04, 15 May 
1959. 

6. Failure of Fighting to Produce Stress in Terms of Adrenal Weight in 
Grouped Male Albino Mice. NM 24 01 00. 04. 06, 15 May 1959. 

7. Potable Water Recycled from Human Urine. NM 19 02 00. 01. 01, 29 May 
1959. 

8. Quantitative Aspects of 1 -norepinephrine Induced Pathologic Changes. 
NM 71 01 21.3, August 1959. 

Naval Medical Field Research Laboratory, Camp Lejeune, N. C . 

1. The In Vitro Assay of Spasmolytic Agents: An Appraisal of Current Tech- 
nique and Recommendations for Modification. NM 02 02 09. 1. 1, and NM 02 
02 09.2. 1, March 1959. 

2. Effectiveness of Suction in Removing Venom from an Open Wound. 
NM 51 03 09. 1.2, August 1959. 

3. The Validity in a Military Setting of MMPI Scales of Dominance and Social 
Responsibility. NM 18 01 09- 1. 1, August 1959- 

4. Comparison of the Radiocardiogram and Evans Blue Dye Dilution Cardiac 
Output Methods. NM 61 01 09. 1. 10, August 1959. 

(To be continued) 

4: j: 4: )|: $ ft 



22 Medical News Letter, Vol. 34, No. 8 



From the Note Book 

RADM Holland Commands NAMC. RADM J. L. Holland MC USN assumed 
command of the Naval Aviation Medical Center, Pensacola, Fla. , on 24 Sep- 
tember 1959. When he ordered hoisted his two-starred flag it marked an 
important first in the long history of that training base for Naval A-viation — 
the first flag officer of the Navy Medical Corps to serve on active duty in 
Pensacola. (News Release, Naval Air Training Command, NAS, Pen jacola.Fla. ) 

CAPT Fuller AFIP Deputy Director . Newly assigned as Deputy Director of the 
Armed Forces Institute of Pathology is CAPT R. H. Fuller MC USN v/ho 
reported from U.S.N. Hospital, Camp Pendleton, Calif. , where he served as 
Chief of Laboratory Service. CAPT W. M. Silliphant MC USN recently retired 
after having served as Director of the Institute for four years. The present 
director is COL F. M. Townsend USAF MC. (AFIP Letter, 1 October 1959) 

Treatment of Cholera . In addition to excellent, simplified, and detailed treat- 
ment of cholera, the Research Report from U. S. Naval Medical Research Unit 
No. 2, Taipei, Taiwan, contains many applicable suggestions for management 
of dehydration from other causes. This Report also includes a simplified 
method for estimation of plasma protein concentration by means of determina- 
tion of the specific gravity of blood, and recommendations for fluid replace- 
ment in dehydration following severe diarrhea. {Treatment of Cholera, 
NM 52 11 02. 3. 4, I August 1959) 

Gastrointestinal Radiology . Continuing the series of Twenty-Five Years of 
Progress articles, the September issue of The American Journal of Digestive 
Diseases presents a comprehensive review of the progress of radiology in 
relation to the gastrointestinal tract, by F. E. Templeton of the University of 
Washington School of Medicine. 

Prednisone in Myocardial Infarction. This report indicates that a beneficial 
effect results from the use of prednisone during the first two weeks following 
the development of myocardial infarction. Disorders of cardiac rhythm and 
of atrioventricular conduction in'particular were reported to be diminished. 
Less success in case of intraventricular disorders of conduction could be 
expected. (G. Toja, F. Accossato, Minerva med. (It.) 50: 765, 1959) 

Blood Dyscrasias and Tolbutamide. A case description is presented wherein 
during the course of tolbutamide therapy for diabetes mellitus a patient devel- 
oped toxic bone marrow depression which, under the influence of adrenal 
steroids, evolved into an acute leukemia. Speculation is raised as to the 
relationship between tolbutamide and the fatal blood dyscrasia. (LT R. C. Brod 
MC USN, J. A. M.A., 19 September 1959) 



Medical News Letter, Vol. 34, No. 8 23 



Fat in Diabetes . In a group of patients with diabetes, retinopathy, and 
elevated serum lipids, a low fat diet resulted in a striking increase in glu- 
cose tolerance, lowering of serum lipids, and marked decrease or disappear- 
ance of fundal exudates. From these observations the author concludes that 
it seems justifiable to consider a strict low fat diet in diabetic patients who 
present elevated serum lipids and distinct retinopathy. (W. Van Eck, Am. 
J. Med. , August 1959) 

Intrathoracic Disease, In 100 consecutive cases in which scalene node biopsy 
was performed as an aid in diagnosis of intrathoracic disease, 60% of those 
with tumor had positive biopsy specimens while a diagnosis of tumor was 
made by the bronchoscopist in 70% of the cases. The writers justly point out 
that these techniques, along with cytologic study, would be more useful as 
complemental techniques rather than any one being employed as a single 
routine diagnostic tool. (A. Gaurie, G. Friedell, J. Thoracic Surg. , 
August 1959) 

Rectal Cortisol . In 16 patients with ulcerative colitis of mild or moderate 
degree confined to the rectum or rectosigmoid, 8 showed a satisfactory 
response to a series of hydrocortisone enemas. In view of the relative 
safety of this form of therapy, it is suggested that it should be considered 
as the initial steroid therapy in many patients with this disease. 
(R.D. Schwartz, et al., A.M. A. Arch. Int. Med., August 1959) 

Intrahepatic Metastases . The determination of the rate of urinary bilirubin 
excretion in patients with increased serum alkaline phosphatase and normal 
serum bilirubin levels offers a more specific means of predicting the pres- 
ence of metastatic carcinoma in the liver than do the latter two findings alone. 
(E. Fitzsimons, et al. , J. Lab. & Clin, Med. , August 1959) 

Cerebral Vascular Insufficiency, Transient visual symptoms are frequently 
experienced by patients with intermittent insufficiency of the carotid or ver- 
tebral systems. Recognition of such prodromal symptoms is important if 
patients are to be treated before a frank stroke occurs. Illustrations and 
diagrams enhance this presentation. { W. Hoyt, A. M. A. Arch. Ophth. , 
August 1959) 

Hypertensive Emergencies . Recommendations are made for management of 
hypertensive crisis, employing some of the newer chemical agents. Details 
of parenteral therapy are given, including those for the employment of a 
solution of sodium nitroprusside when more conventional hypotensive agents 
are ineffective, contraindicated, or productive of prohibitive side effects. 
(R. Gifford, Proc. Staff Meet. Mayo Clin., 5 August 1959) 



24 Medical News Letter, Vol. 34, No. 8 




DENTAL UAm s SECTION 



Pulp Capping 

Many teeth that have exposed vital pulps caused by mechanical means, 
traumatic injury, or decay that has extended into the pulp chamber can be 
saved with proper use of calcium hydroxide suspensions. 

Favorable conditions for pulp capping with calcium hydroxide are: 
{1) a tooth with a vital pulp; (2) fresh hemorrhage from the canal; (3) roent- 
genograph^ examination revealing conditions which are normal except for 
the pulp exposure; (4) removal of all decay; (5) good cavity preparation, and 
(6) sterile field. Calcium hydroxide stimulates the formation of bridges of 
secondary dentin in the pulp. 

In most instances, the possibility of an exposure can be foreseen. If 
this be so, it is imperative that the outline form be completed before excavat- 
ing into the pulp chamber. The tooth should be isolated with a rubber dam, 
and after the outline form is completed with proper extension for prevention, 
smooth margins, and other operative procedures, the area should be painted 
with iodine tincture, merbromin, or some other equally efficient solution, 
and a completely fresh set of sterile instruments placed on the operating tray. 
Removal of the decay just over the pulpal region may or may not lead to an 
exposure; therefore, care must be taken during this procedure. The instru- 
ments of choice are extremely sharp excavators or round burs. If the pulp 
is not penetrated, the base and final restorative material should merely be 
inserted. In the event of an exposure, the dentist should excavate with sweep- 
ing motions until all decay is removed. 

Usually, hemorrhage will cease momentarily on its own; otherwise, a 
sterile cotton pellet saturated with epinephrine (1: 1000 concentration) will 
help control the bleeding. Next, the area should be cleaned with hydrogen 
peroxide (3%) and dried with a sterile cotton pellet. The tooth is then ready 
for calcium hydroxide. 

Enough calcium hydroxide should be squeezed from the tube to cover the 
exposed area. With the back of an excavator, the calcium hydroxide should be 
brushed over the area. A very slow stream of warm air should be directed on 
the calcium hydroxide for a few seconds and then the calcium hydroxide should 
be gently patted into place with a dry cotton pellet. The air helps the substance 
set, so that it is not sticky. In order to avoid forcing any of the material into 
the pulp chamber, only slight pressure is exerted during this operation. 



Medical News Letter, Vol. 34, No. 8 25 

An excellent base to use over the calcium hydroxide is zinc oxide and 
eugenol with zinc acetate crystals added so that the base will set immediately. 
The final restoration should be placed at the same sitting so that a tight seal 
is insured. (Levin, J. J. , D. D. S. , J. Am. Dent. A., Vol. 59 , August 1959} 

$ $ $ 4 4 $ 
Dental Standards for Submarine Personnel 

Candidates for submarine training shall conform to the dental standards 
herein quoted from Chapter 15-29 (f) of the Manual of the Medical Department. 
Particular care must be exercised in the preliminary dental examination on 
ships and at shore stations in order that a large number of candidates may not 
be rejected as a result of reexamination at the Submarine School in New London, 
Conn. , thus avoiding needless cost of transportation, loss of service, and in- 
complete quota of classes. 

A complete dental examination shall be conducted by a Dental officer 
if available. If a Dental officer is not available, the examination shall 
be conducted by a Medical officer. Candidates must have sufficient number 
of natural and/or artificial teeth to insure satisfactory masticatory and 
incisal function. Acute infectious diseases of the soft tissues of the oral 
cavity are disqualifying until remedial treatment is completed. Individuals 
with caries shall have all required dental treatment completed before trans- 
fer to the submarine training unit. A candidate who will require dental 
prosthetic restorations during the period of training should be considered 
not physically qualified. Malocclusion (crossbite, over jet, or overbite with 
or without impingement) is not cause for physical disqualification unless it 
interferes with incisal or masticatory function to such degree that adequate 
nutrition cannot be obtained from food normally served as a regular diet by 
a general food service. Missing teeth replaced by satisfactory bridges or 
dentures shall not be considered disqualifying. 

3fC Jfc 39C 9p Jp 3JC 

Naval Dental School's Continuous Training Program 

A short course in Oral Pathology will be presented by the U. S, Naval 
Dental School, NNMC, Bethesda, Md. , 7 - H December 1959, and 7-11 
March I960. 

The course is designed to increase the knowledge of the Dental officer 
in oral pathology and oral diagnosis. Disturbances in developments, diseases 
of the oral mucosa and jaws, the oral manifestations of certain systemic dis- 
eases, and benign and malignant oral neoplasms will be discussed in detail, 
and their clinical and microscopic characteristics illustrated with slides. 
Lectures will be correlated with case presentations, microscopic seminars, 



26 Medical News Letter, Vol. 34, No. 8 



and round table discussions. Quotas have been assigned to various District 
Dental Officers. Applications should be submitted to: Chief, Bureau of 
Medicine and Surgery (Code 6) via the appropriate District Dental Officer, 



" The Navy Dental Corps" - A New Film 

The U. S. Navy Dental Corps exhibited its new motion picture, "The 
Navy Dental Corps, " for its first public showing at the Centennial Session 
of the American Dental Association in New York City. This film portrays 
the professional and family life of a young Navy Dental officer from the time 
just prior to his being ordered to active duty upon graduation from dental 
school through an interval of approximately five years. His early training, 
various duty assignments, postgraduate education, and finally, duty at the 
U.S. Navy Dental School, National Naval Medical Center, are shown. The 
filming took place at the NNMC, at naval facilities in the San Diego, Calif. , 
area, and in some instances, in the homes of Dental officers. 

Information regarding this film or its use may be obtained by writing 
to: Chief, Bureau of Medicine and Surgery (Code 6), Navy Department, 
Washington 25, D. C. , or to the appropriate Naval District Film Reference 
Library. 



Personnel News 

RAlJM C.C. DeFord DC USN has relieved CAPT R. S. Snyder, Jr. , 
DC USN as Inspector General, Dental. CAPT Snyder will serve as Assistant 
to the Inspector General, Dental. RADM DeFord, with LCDR R. E. Ricker 
MSC USN, Administrative Assistant to the Inspector General, Dental, will 
join the Inspector General, Navy, in October, in conducting a comprehensive 
survey of Eastern Atlantic and Mediterranian dental facilities. 

LTCOL Dominador G. Santos, President, Philippine Dental Association, 
and Chief Dental Surgeon of the Philippine Constabulary, and Doctor Lorenzo 
G. Almeda, President, Manila Dental Society, Philippines, recently visited 
RADM C. W. Schantz DC USN, Assistant Chief, Bureau of Medicine and 
Surgery (Dentistry), and Chief, Dental Division, and his staff. 

RADM C. W. Schantz DC USN was delegate for the Navy and represented 
the Secretary of the Navy at the Centennial Session of the A. D. A. in New York 
City, 14 - 18 September 1959. CAPT A. R. Frechette DC USN, Deputy Chief 
of the Dental Division served as alternate delegate to the meeting. The Navy 



Medical News Letter, Vol. 34, No. 8 27 



Dental Corps was represented in various committee hearings by the following 
officers: 

Federal Dental Service RADM C. W. Schantz DC USN, and 

CAPT A. R. Frechette DC USN 
Dental Education CAPT E. G. F. Pollard DC USN 

Dental Research CAPT J. A. English DC USN 

Public Health CAPT W. R. Stanmeyer DC USN 

Hospital Dental Service CAPT R. G. Gerry DC USN 

5jl 5jC i,i 5JC ip. 5jC 



RESERVE ^liip^ SECTION 




Tables of Organization for Naval Reserve, Fiscal Year I960 
BuPers Instruction 5400. 1H, 1 July 1959 

(Continued from Medical News Letter, 2 October 1959) 

6. Command Pay . Commanding Officers of pay units of the Selected Reserve 
except Commanding Officers of those units which are established on a district - 
wide quota basis, are authorized to receive compensation for the performance 
of the duties of command, including the proper administration of their units, 
at the rate per annum set forth in the following table: 

Total Allowances Command Pay Authorized 

*$100 or more $240 

50 to 99 180 

25 to 49 120 

10 to 24 72 

* NOTE: Brigade, Battalion, andDE Division Commanders 
in all cases command organizations of more than 
100 personnel. 

The appointment of an officer as Commanding Officer of a pay unit of the 
Selected Reserve does not automatically entitle Mm to receive compensation. 
If the officer concerned has not, in the opinion of cognizant Commandant or 
Chief of Naval Air Reserve Training, performed these duties in satisfactory 
manner, command pay shall not be paid to him. 



28 Medical News Letter, Vol. 34, No. 8 

7. Pay Status of Members of Specialist Units and Officer Schools, and 
Requirements for Conforming Units 
a. Specialist Units Other than NROS 

(1) Pay billets are authorized for the Commanding Officer and certain 
staff members of specialist units as compensation for the faithful perform- 
ance of duties in connection with the administration and training of their units. 
Commanding Officers will be designated only by Naval District Commandants. 
Staff members will be designated by Commandants, based on recommendations 
of Commanding Officers concerned. Staff members may include commissioned 
officers, warrant officers, or enlisted personnel. Duties which staff members 
perform will include such billets as Executive Officer, Training Officer, Person- 
nel Officer, Instructor, et cetera. Orders to Commanding Officers and staff 
members will be prepared on Form NavPers 3090, Naval Reserve Inactive Duty 
Training Orders. It is desirable that staff member pay billets be rotated from 
time to time among various members of the unit in order to provide greater 
variety of training; however, such rotation should not normally take place more 
often than once annually for each billet. 

(2) Limitations . Any Specialist unit which has an enrolled membership 
of fifteen (15), but not more than twenty-nine (29) members, qualifies for pay 
status for the Commanding Officer and one (1) staff member. For each addi- 
tional fifteen (15) members, over and above the original fifteen (15), pay 
status is authorized for one (1) additional staff member; however, no more 
than five (5) pay billets are authorized for any Specialist unit. Commanding 
Officers and staff members shall not receive pay for more than a total of 
24 drills annually, such total to be based on no more than eight drills per 
quarter. In order for Commanding Officers and staff members to be eligible 
for compensation as outlined herein, the combined membership of the unit with 
which they are affiliated must maintain a minimum attendance of 75% per quar- 
ter, such percentage to be based on attendance at all drills scheduled by the 
unit concerned for that quarter. The performance of equivalent drills may be 
included with regular drills in computing unit percentages of attendance. Drills 
missed as a result of active duty for training may be counted as ''present" for 
this computation. Pay billets for all Specialist units will be limited to quotas 
established by Table 25. Attendance by U. S. Marine Corps and U. S. Coast 
Guard Reservists may be included in percentage computations; however, atten- 
dance by personnel of the Reserve components of other branches of the Armed 
Force3 may not be included. 

b ' Naval Reserve Officer Schools . Pay billets are authorized for directors 
and for staff and faculty members of Naval Reserve Officer Schools. These 
billets will be limited to the quotas established in Table 24 and will be admin- 
istered and regulated in accordance with BuPers Instruction 1520. 33A. 

c * Conforming Units of the Specialist Reserve. Units of the Specialist 
Reserve complying with the following stated provisions, as determined by the 
cognisant Commandant, will be considered "Conforming Units. " (1) The author- 
ized number of drills were scheduled and conducted, (2) The approved training 
program was followed. (3) Each drill, period was of at least two hours' duration. 



Medical News Letter, Vol. 34, No. 8 29 



Units that are not determined to be "Conforming Units" will be considered to 
be "Non- Conforming Units. " Neither retirement point credit nor pay is auth- 
orized for any member of a "Non- Conforming Unit" for the period that the 
unit was determined to have been non-conforming. 

8. Establishment and Activation or Commissioning of Units 
a. Naval Reserve Programs (less aviation ) 

(1) Definitions . For the purpose of Naval Reserve Programs admin- 
istration, the following definitions shall apply: 

(a) Establish. The granting of authority to form a Naval Reserve 
unit at a specific location with a prescribed allowance. 

(b) Activate , The granting of authority to commence prescribed 
training and carry out normal administrative functions by a specific unit. 

(Z) Authority . Selected Reserve units may be established and activated 
only by authority of the Chief of Naval Personnel. Authority to establish units 
of authorized Specialist Programs is vested in the Chief of Naval Personnel. 
Authority to activate established Specialist units is delegated to cognizant 
Commandants . 

(3) Procedure 

(a) Establishment . All requests for establishment of units shall 
be submitted to the Chief of Naval Personnel and shall include the following 
information: 

J_. Desired location 

2. Desired date 

3. Proposed size 

4. Proposed identifying number 

5. Proposed drill night (not necessary if multiple drills 
are contemplated) 

6. Statement as to adequacy of training facilities, equipment, 
and number of stationkeeper personnel available to support the unit. Requests 
for establishment of Reserve Crews shall include a report of availability of 
suitable and adequate berthing facilities, including dockside utilities, where 
applicable. 

(b) Activation . All requests for activation of Selected Reserve 
units shall be submitted to the Chief of Naval Personnel and shall include the 
following information: 

1. Desired date 

2. A roster of officers that are pledged to enroll. (Form 
NavPers 353 shall be used.) 

3. The number of enlisted personnel, by rating and pay grade, 
and that are pledged to enroll. (Names are not necessary.) 

(It should be noted that the granting of authority to establish a Selected Reserve 
unit does not automatically grant authority for activation. Requests for con- 
current establishment and activation may be submitted, but must contain all 
the information required above. ) 



30 Medical News Letter, Vol. 34, No. 8 



b. Naval Air Reserve Programs 

{1} Definitions. For the purpose of Naval Air Reserve Programs 
administration, the following definitions shall apply: 

(a) Commission . The granting of authority to commence pres- 
cribed training and carry out normal administrative functions by a specific 
unit and the imposition of responsibility therefor. 

(b) Activate . The transfer to full time active duty status of Naval 
Air Reserve unit. 

(2) Authority . Naval Air Reserve Program units may be commissioned 
only by authority of the Chief of Naval Operations. 

(3) Procedure . Pre commissioning and activation procedures shall be 
as prescribed by the Chief of Naval Operations. 

■Ja Jr .1- «I> aJU <J> 

Jf. Jp~ *p .■,■. .-,•. . , . 

American Board Certifications - 
Inactive Reserve Officers 

American Board of Dermatology 

LT Evans S. Farrington (MC) USNR 
LT Howard S. Yaffee (MC) USNR 

American Board of Internal Medicine 

LTJG Lawrence F. Blackburn (MC) USNR 

LTJG Warren W. Cline (MC) USNR 

LT Harry L. Davis (MC) USNR 

LT Robert E. Doan (MC) USNR 

LT Harold W. Evans (MC) USNR 

LTJG John L. Magness (MC) USNR 

LT Richard L. Sterkel (MC) USNR 

American Board of Obstetrics and Gynecology 

LTJG George L. Austin, Jr. , (MC) USNR 

LCDR John K. Cox (MC) USNR 

LCDR Howard E. Milliken, Jr. , (MC) USNR 

American Board of Orthopedics 

LT Leo B. Meyer (MC) USNR 

American Board of Pathology 

LT Lewis Brooks (MC) USNR 

LT Harry M. Carpenter (MC) USNR 

LT Edward M. Kelman (MC) USNR 



Medical News Letter, Vol. 34, No. 8 



American Board of Pediatrics 

LT George W. Bean (MC) USNR 
LT Jack P. Keeve (MC) USNR 

American Board of Psychiatry and Neurology in Psychiatry 
LT Claude B. Henderson (MC) USNR 
LT Edwin C. Moore (MC) USNR 

American Board of Surgery 

LCDR William A. Cherry (MC) USNR 
LT Walter S. Henley (MC) USNR 
LCDR Harry N. Iticovici (MC) USNR 
LCDR Thomas C. Lyons (MC) USNR 
LCDR William M. Moss (MC) USNR 
1/T Robert L. Tornello (MC) USNR 

American Board of Urology 

LT Lawrence J. Morin (MC) USNR 

$ ajt 9$t sjs sji $ 

Convention of Association of Military Surgeons 

The Association of Military Surgeons will hold their annual convention 
at the Mayflower Hotel, Washington, D. C. , 9-11 November 1959. This 
meeting will have as its theme, "Practice of Military Medicine - Broadening 
Concepts, " and will present subjects which will afford those in attendance an 
excellent opportunity to remain abreast of the latest developments in military 
medicine. Eligible inactive Naval Reserve Medical Department officers may 
earn one retirement point credit for attendance at each daily session provided 
they register each day with the military representative present. 

«s!e aBe rfc ata ft 
r,t *y» •%* *f* .-,-. 

Policy 

The U.S. Navy Medical News Letter is basically an official Medical 
Department publication inviting the attention of officers of the Medical 
Department of the Regular Navy and Naval Reserve to timely up-to-date 
items of official and professional interest relative to medicine, dentistry, 
and allied sciences. The amount of information used is only that necessary 
to inform adequately officers of the Medical Department of the existence and 
source of such information. The items used are neither intended to be, nor 
are they susceptible to use by any officer as a substitute for any item or 
article in its original form. All readers of the News Letter are urged to 
obtain the original of those items of particular interest to the individual. 



32 Medical News Letter, Vol. 34, No, 8 



AVIATION MEDICINE DIVISION 




The Cardiac Stress Two-Step Test 

Cardiac stress tests are used for the purpose of evaluating the presence 
of cardiac disease not detectable by other means. Such a test should not be 
done indiscriminately in the presence of a resting abnormal electrocardio- 
gram (ECG) or clinically established cardiac disease. It should not be per- 
formed in the presence of premonitory pains of impending myocardial infarc- 
tion or in a subject experiencing the first episode of angina. The latter event 
may represent acute infarction. 

If it is elected to perform an exercise tolerance test, it should be done 
in a standardized manner that permits comparative clinical evaluation. A 
complete 12-lead resting ECG (I, II, III, aVr, aVl, aVf, and 6 V leads) should 
be taken prior to testing. The standard test is given according to the method 
of Master (Am. Heart J. , j_0:495; 1935). The subject makes a given number of 
trips across two standard steps in accordance with age, sex, and weight. Each 
of the two steps is 9 inches high, 8 to 10 inches deep, and 18 to 27 inches wide. 
An ascent or trip is made by going up one side of the two steps and down the 
other. The return trip constitutes the second ascent. With a single two-step 
test, the number of ascents must be completed in a minute and a half; with the 
double two-step test, twice the number given for the single test, the number 
of ascents is completed in 3 minutes. 

The test is performed in the fasting state with smoking interdicted for 
several hours. Preferably, the patient should not be under the influence of 
cardiovascular drugs at the time of the test. If so, medication should fa? 
indicated (on the report). 

The object of the test is to detect changes in the postexercise ECG that 
were not present in the resting tracing. For this purpose, it is desirable to 
record after exercise a minimum of leads — I, II, III, and precordial leads 
V2 and V5. These should be recorded immediately after exercise, 2 minutes, 
5 minutes, and 8 minutes after exercise. In the event the tracing has not 
returned to normal by 8 minutes, subsequent records should be taken until the 
tracing has returned to its resting level. 

During the performance of the test a physician should be readily avail- 
able. If there is clinical reason to suspect coronary artery disease, it is 
advisable to begin with a single two-step test; in the event that it is not 



Medical News Letter, Vol. 34, No. 8 33 



abnormal, a subsequent double two-step test may be performed. A doctor 
should be in immediate attendance if there is any suspicion of coronary artery 
disease. A period of at least 2 hours should elapse between the two tests. 
The test should be terminated immediately upon the development of suspicious 
symptoms or pain on the part of the examineee. 

For subsequent evaluation of such test procedures, it is imperative that 
the examining physician clearly indicate the following: (1) number of steps 
taken; (2) length of time taken for the two-step test; (3) identification of each 
lead used in the test; (4) identification of the resting ECG; and (5) exact time 
of recording of each postexercise tracing, e.g. , immediate, 2-minute post- 
exercise. 

It is emphasized that the performance of the exercise tolerance test is 
not considered to be a routine procedure. When a test is interpreted as being 
positive, the criteria for making this diagnosis should be given under the inter- 
pretation section of the Standard Form 520, Electrocardiographic Report. 

Considerable variation in interpreting the criteria for a positive exer- 
cise tolerance test exists. When minor changes are considered as positive, 
a large number of normal subjects will have a positive test. Using more, 
exacting requirements, some individuals with coronary artery disease will 
have a normal response. It should be remembered that some individuals with 
coronary artery disease will have normal responses by all available criteria, 
and variations in tests done on the same subjects from one time to the next 
are to be expected. 

Changes in the amount of stress to extreme degrees can result in elec- 
trocardiographic changes in greater numbers of normal subjects. 

At present, the criteria of Manning {Am, Heart J. , 54:923; 1957), 
Mattingly {Research Report No. 75-57, Walter Reed Army Institute of Research, 
May 1957), and Lepeschkin (New England J. Med. , 258 : 511; 1958) provide a 
basis for reasonably accurate interpretations. 

Mattingly 's criteria are: ( 1) ' . . .the best and probably the only valid 
criteria for a positive test indicative of coronary insufficiency in the post- 
exercise electrocardiogram was found to be ischemic ST segment depression 
in excess of 0. 5 mm. in any lead. (2) Transitory ST junction depression after 
exercise is usually a normal finding. ST junction depression persisting sev- 
eral minutes after exercise and return of the heart rate to normal may be due 
to myocardial anoxia in exceptional cases. (3) Isolated T-wave alterations in 
the postexercise electrocardiograms are not valid evidence of coronary insuf- 
ficiency. " 

The criteria of Manning are included in his comments: "False segment 
depressions in the tracing immediately following exercise and variations in 
the T-wave in the normal were frequent. The only valid change in the post- 
exercise tracing that constitutes a positive response is a flat depression of 
the RS-T segment as compared to the P-R segment which subtends to an angle 
of 90° or more with the vertical and persists to at least the 2-minute tracing. 



34 Medical News Letter, Vol. 34, No. 8 



A depression with, these characteristics of 1 mm. constitutes,, we feel, an 
unquestionably positive response. Depressions ranging from 0. 5 to 1 mm. , 
provided they possess the true flat characteristics, are considered question- 
able and likely positive. " 

The criteria advocated by Lepeschkin are given in his comment: "The 
combination of criteria for a positive test that gave the least amount of over- 
lapping, being present in 94% of the true and in only 23% of the false tests is 
as follows: inversion of the T -wave in lead I or depression of the ST segment 
junction beyond the continuation of a PR interval of 0. 75 mm. or more, the 
return of the ST segment to the baseline at this time taking place in the second 
half of the QT interval, and ST segment depression of 0. 5 mm. or more last- 
ing for 2 minutes or more. " 

In recommending the interpretation to be used for flying personnel, one 
may use the three above expressed opinions. Care should be taken to not 
interpret exercise records which have significant baseline ST segment eleva- 
tions commonly seen in young individuals, as many of these will produce false 
positive responses. It is suggested that, for the present, a positive test be 
one which has 1 mm. of ST segment depression in any lead as long as the ST 
segment depression is a flat or plateau change and is depressed compared to 
the PR segment or is progressively slanted downward after the onset of the 
initial depression, Borderline tests should consist of plateau ST segment 
depression of 0, 5 mm. to 1. mm. in any lead. 

It should be remembered that large changes in ST segments, T -waves, 
and P-waves frequently occur in the standing position. All criteria for exer- 
cise changes in the electrocardiogram must be based on records taken in the 
recumbent position. 



Pressure Changes in the Middle Ear After Flight 

When a pilot ascends or descends in the atmosphere he is exposed to 
a continually changing environmental pressure. The pressure of gas in the 
middle ear space, however, does not exactly follow that of the atmosphere, 
but does so in a discontinuous, stepwise manner owing to resistance in the 
sole communicating channel, the Eustachian tube. Therefore, intermittent 
pressure differentials build up between the inside and outside of the ear. 
Normally these are felt as no more than a sense of fullness during ascent 
and suction during descent, followed in either case by an intermittent sense 
of "clearing" at re -establishment of equilibrium. Owing to a nonreturn valve 
defect in the Eustachian tube, clearing sometimes proves difficult during des- 
cent and at such times suction can develop causing deafness, pain, retraction, 
and congestion of the eardrum, middle ear effusion, and sometimes in severe 
cases, rupture of the eardrum. Occasionally, vertigo is experienced at the 



Medical News Letter, Vol. 34, No. 



35 



moment of clearing. During flight the pressure differentials which give ri3e 
to these conditions are due to alterations in atmospheric pressure. During 
flight the gas content of the middle ear remains relatively constant. 

Following the use of 100% oxygen in flight, it is common to experience 
similar sensations, sometimes leading to delayed signs and symptoms, after 
landing. With no further flying, the subjective magnitude of the delayed effect 
gradually decreases until after 24 hours they are usually no longer noticeable. 

Since oxygen is absorbed through the mucous membrane of the middle 
ear and sealed to escape from the vascular network of the mucous membrane 
the composition of the gaseous mixture in the middle ear varies from that in 
the atmosphere. The estimated composition of middle ear equilibrium gas 
mixture is shown in the table. 



Gas 



Partial Pressure 
(mm. Hg.) 



Percentage Content 

by Volume 
(At. - 760 mm. Hg.) 



Oxygen 
Water vapor 
Carbon dioxide 
Nitrogen 



66 

47 

50 

597 



8. 7 
6.2 
6.6 

78. 5 



Experiments have been conducted which show that after flight using 
100% oxygen there is a tendency for the middle ear pressure to fall below 
that of the atmosphere. The observed rates of fall are small but they are 
persistent, and in the event of failure to establish communication between 
middle ear space and nasopharynx, considerable suction can develop. In 
this event, middle ear trauma could ultimately occur and it seems probable 
that herein lies the physical cause of the delayed signs and symptoms prev- 
iously mentioned. 

It has been shown that the main cause of the observed physical findings 
is absorption of oxygen from the closed middle ear space. The fall in pressure 
in the middle ear is delayed until 30 to 40 minutes after final descent. This is 
due to the saturation of the gas with water vapor which rapidly develops to 
47 mm. Hg. Carbon dioxide diffuses from the tissue to form an equilibrium 
of approximately 30 to 40 minutes. Nitrogen is diffused into the middle ear at 
a rate of approximately 0. 3 ml. /hr. Oxygen is absorbed at a rate of approx- 
imately 3 ml. /hr. . The differences in rate of diffusion of these two gases 
would therefore account, in the event of a closed Eustachian tube, for the 
difference in pressure which develops in the middle ear over the following 
24-hour period. 



36 Medical News Letter, Vol. 34, No. 8 



Trauma liable to be incurred by development of absorption of such 
excess oxygen is essentially acute in onset and mechanical in nature. It is 
possible that the high concentration of oxygen exerts a toxic influence upon 
the mucous membrane and, since above normal concentrations may remain 
for over 24 hours after flight, it can be appreciated that the middle ear of an 
aviator engaged in regular flying duties is liable to be continually exposed to 
this influence over long periods of time. This condition can be extended to a 
partially obstructed nasal sinus where a similar situation could obtain. 

With greater use of continuous flow oxygen regulators which provide 
100% oxygen, it is possible that the incidence of delayed aero-otitis media 
among pilots may increase. As a preventive measure, it is suggested that 
pilots who are frequently required to use 100% oxygen in flight be instructed 
in the use of the reverse Valsalva maneuver. This maneuver should be used 
immediately after landing and again 30 minutes later. A reverse Valsalva 
maneuver produces negative pressure within the nasal and buccal cavities 
emptying the middle ear of the 100% oxygen trapped there. This is done by 
taking a mouthful of water, firmly closing the mouth, holding the nose tightly 
shut, then swallowing the water. After taking a breath, the air pressure in 
the middle ear can be equalized with ambient air by performing the Valsalva 
maneuver. (B. Melville Jones, Pressure Changes in the Middle Ear after 
Flight (abstracted in part): Institute of Aviation Medicine, RAF, Farnborough) 

■- ' - «-" -■ ■- ■ - - '.- •,'■'■ tXr- 

^f* : V - ■*(«. Jff- ^V -"|» 

Correct Parachute Descent and 
Landing Procedures 

The Bureau of Aeronautics has a new training film MN 9299b, "Parachute 
Landing Techniques, " which will be released soon. The correct techniques 
shown therein are the result of a BuAer requested study at the Naval Parachute 
Unit. 

To assist in survival, BuAer is also changing the attachment of the PK II 
so that it can be reached. A bulletin is in preparation. 

It has been emphasized that pilots do not know their equipment well 
enough to handle emergencies by reflex action. The triad is (1) Practice, 
(2) PRACTICE, (3) P-R-A-C-T-I-C-E! ! ! Here are the procedures: 

DESCENT OVER LAND - STANDARD HARNESS. When the standard parachute 
is used (either the back, chest, or seat type) without a life raft, and bailout is 
made over land, the jumper is concerned with landing in suitable terrain and 
getting free' of harness and parachute if there is danger of being dragged by 
winds. 

1. The parachutist should not attempt to get into a sitting position. 

Landing in the seated position on land can cause serious injury if his legs 

tuck under him. 



Medical News Letter, Vol. 34, No. 8 37 



2. Hold both hands on the risers, feet apart 12"- 18'] and knees slightly 
bent just prior to touch down. This allows the man to- hang limp in the 
harness and take most of the ground impact with his legs. 

3. As soon as the feet touch the ground, tumble in the direction of the 
fall. Do not attempt "stand-up" landings. 

4. When a strong wind is blowing the jumper should deflate his canopy 
immediately. This can be accomplished by pulling in on the suspension 
lines closest to the ground. 

DESCENT OVER LAND - INTEGRATED HARNESS WITH CANOPY RELEASE 

1. If the parachute was opened automatically, the manual ripcord must 
be pulled from the pocket during descent to insure immediate separation of 
the jumper from the canopy. The left riser will not be free of the pack until 
the ripcord housing is pulled free from the riser. 

2. The canopy releases should be actuated immediately upon touching 
the ground. The canopy is now completely free of the jumper. 

3. The seat pan and pararaft assembly are removed by releasing the 
lap belt fittings. 

DESCENT OVER WATER - STANDARD HARNESS. A water landing presents 
an additional survival problem. Familiarity and practice with the equipment 
will greatly increase a man's chances of survival. 

1. Do not attempt to sit back in the harness. The time spent attempt- 
ing this feat can be better spent preparing for the landing. 

2. Check the pararaft lanyard to be certain that it is attached to the 
life vest and is routed under the leg strap. The loss of the survival kit 
and pararaft may mean the difference between life and death. 

3. The chest strap should be unsnapped, and risers grasped overhead. 
This will aid in quick escape from the harness when entering the water. 

4. Just prior to feet touching the water, the hands should be placed over 
the leg ejector snaps. Do not release snaps until actually in the water. 

5. Release both leg ejector snaps immediately upon entering the water. 

6. Inflate the life vest, regardless of whether the harness and canopy 
are completely free. By following the pararaft retaining line, remove 
and inflate the pararaft. 

It is not recommended that the pararaft be removed from its container 
while descending. The raft may "fall up. " This introduces the possibility 
of the raft and sea anchor entangling with the canopy and suspension lines 
of the parachute. 

DESCENT OVER WATER - INTEGRATED HARNESS AND CANOPY RELEASE 
1. If the parachute was actuated by an automatic parachute actuator, it 
must be remembered to remove the manual ripcord from the pocket, prefer- 
ably during descent, to insure separation of jumper from canopy. 



38 



Medical News Letter, Vol. 34, No. 8 



2. Unhook the left lap belt fitting. The pararaft kit will hang from the 
right fitting and be more easily accessible when in the water. 

3. The parachutist must check pararaft lanyard to be sure that it is 
attached to the harness. This will insure retention of raft when it is re- 
moved from the survival kit. 

4. Position the hands on the risers adjacent to the canopy releases 
and release the canopy releases immediately upon entering the water. 

5. Inflate the life vest by a positive jerk on each toggle, then remove 
and inflate the pararaft. 

Do not inflate the M3C life vest prior to entering the water. 

These procedures have been laboratory tested, used by test jumpers 
under all conditions of land and water descents, and have been successfully 
used by fleet pilots and crewmen when their lives depended upon them. 

****** 

Candidates Physically Disqualified on 
Final Examination at Pensacola 

Of the last class of student naval aviators reporting to Pensacola for 
flight training, 15 were rejected because of defective auditory acuity. This 
late development disrupts the individual's plans, causes embarrassment to 
the individual, creates hard feelings toward the Navy, and results in a useless 
expenditure of Navy money. It is imperative that a candidate for flight train- 
ing be given a careful, thorough original examination and that all disqualifying 
defects be discovered at that time. The examining flight surgeon is not doing 
the individual or the Navy a favor by passing a questionable or failing candidate 
in the hope that he may slip through the examination at Pensacola. The best 
interest of all parties concerned is served by eliminating the physically or aero- 
nautically unfit as soon as possible. 

****** 

Physical Qualifications for Assignment to Naval 
Air Technical Training Unit Schools 

It has been reported that an increasing number of students are reporting 
to the Naval Air Technical Training Unit Schools who do not meet the visual 
or other physical requirements for this assignment. Article 15-69 (10), 
Manual of the Medical Department, describes the physical qualification re- 
quirements. 

The Official Bulletin of Schools and Courses, Fiscal Year I960 Edition, 
issued by the Naval Air Technical Training Command specifies on page 4 under 



Medical News Letter, Vol. 34, No. 8 39 



"Qualifications and Service Requirements" that "in selecting personnel for 
transfer. Commanding Officers must comply with the qualifications for 
eligibility. " Page A-3 of this publication states in part that the candidate 

"must meet the physical requirements for Air Controlman as set forth in the 
Manual of the Medical Department. Students entering the school must pos- 
sess written proof of pnysical qualification, statement from a flight surgeon 
{Standard Form 88). , . . This evidence is required by the FAA for CTO 
examinations. . . . ' 

Completion of Standard Form 88 

Many reports of physical examination on Standard Form 88 are being 
received in the Bureau of Medicine and Surgery with inaccurate or incom- 
plete information. Much time and money are lost by these practices. The 
examining or reviewing flight surgeon should review the SF 88 at the time of 
signing to check the accuracy of all recorded findings so that BuMed may 
intelligently inform BuPers of the pilot's flight status. It is not generally 
understood that frequently BuMed also must answer congressional inquiries 
regarding the physical condition of naval ayiation personnel. All too often 
there is an embarrassing lack of information. Then, the Bureau has no 
recourse but to return the SF 88 for completion. Forms are frequently 
received with Item 5, "Purpose of Examination, " filled in with "Post Hos- 
pitalization" without further explanation. It is necessary to include such 
information as whether the examinee was hospitalized for medical or surgi- 
cal reasons, dates of hospitalization, and complications. If the flight surgeon, 
on preparing the SF 88, will keep in mind that a letter may have to be written 
to BuPers or to a Congressman based on the information furnished, he can 
frequently anticipate BuMed needs and give full facts, including summary of 
hospitalization, consultation reports, et cetera, at the time of examination. 

■fc «Ac sAs sis 3$E A 

Accident Reports 

The Medical Officer's Report of Aircraft Accidents /Incidents and 
Ground Accidents continues to be received at the Naval Aviation Safety Center 
submitted on the old form (OpNav Form 3750-8 Rev, 2-54). This poses a very 
difficult situation in the coding and analysis of the information contained in 
the MOR. These reports should be submitted on OpNav Form 3750-8 (Rev. 5-58). 
Difficulty in obtaining the new forms has been attributed to overstocking of this 
form by a few activities. 



40 



Medical News Letter, Vol. 34, No. 8 



Message from the Surgeon General 

A letter has come to me from a Naval Reserve Medical Officer who 
recently completed his active duty. He expressed deep appreciation and grat- 
itude for the excellent indoctrination and guidance he received from a Medical 
Service Corps officer. The writer sums up his reaction by saying, "Through 
his example and advice I gained an enthusiastic appreciation of our Navy, its 
Medical Corps and its Medical Service Corps. " 

It is most gratifying to receive such a communication. It is concrete 
evidence of the effectuation of our contining policy of helpfulness to newly 
enrolled Medical Department officers, particularly during the days of their 
adaptation to the Navy environment. Medical Service Corps officers are par- 
ticularly well equipped to be of assistance in this direction. Such performance 
on their part goes far in promoting the satisfactory service of others in the 
Medical Department. 

It is well to note that the officers who are so helpful in this regard are 
always those who are very competent in their total performance. This is 
pointed up by the Medical officer who wrote the letter at hand when he said, 
referring to the officer he was commending, "his administrative ability and 
his intimate knowledge and sincere appreciation of each organization's objec- 
tives, capabilities, and limitations was, in my opinion, exemplary. ' 



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